1st Generation Drug-eluting Stents Research Articles

Mechanisms of Very Late Stent Thrombosis in Japanese Patients as Assessed by Optical Coherence Tomography

BackgroundAlthough very late stent thrombosis (VLST) remains an important concern, the underlying etiology and clinical characteristics are not fully elucidated in Japanese patients who undergo intravascular imaging-guided percutaneous coronary intervention (PCI) regularly. MethodsWe identified 50 VLST lesions (bare-metal stent [BMS] [n = 16], first-generation drug-eluting stent [DES] [n = 14] and newer-generation DES [n = 20]) in patients managed in our institutes. The underlying mechanism of VLST was assessed by optical coherence tomography (OCT), and the major etiology of each lesion was determined. The aim of this study was to explore the mechanisms of VLST of BMSs and DESs in Japanese patients. ResultsThe median duration since stent implantation was 10 years (range: 1-20). The most frequent etiology of VLST was neoatherosclerotic rupture (44%), followed by neointimal erosion (24%). Edge disease (10%) and evagination (10%) were similarly observed. Malapposition (8%) was deemed to be acquired late by looking at intravascular imaging from the index procedure. Uncovered struts (2%) and in-stent calcified nodule (2%) were the least frequent etiologies. Regardless of etiology, signs of neoatherosclerosis were present in most lesions (82%). Most patients received single (68%) or dual (8%) antiplatelet therapy or oral anticoagulation alone (4%), whereas a considerable proportion of patients discontinued medication (20%). Regarding the treatment strategy, drug-coated balloon was the most frequent strategy (56%), followed by implantation of newer DESs (34%). ConclusionsVarious mechanisms have been identified in Japanese patients with VLST. In these patients, biological responses seemed to be more relevant than the index procedure-related factors.

Comparison of Clinical Outcomes Among Various Percutaneous Coronary Intervention Strategies for Small Coronary Artery Disease

It remains unclear which percutaneous coronary intervention (PCI) strategy is the most preferable in patients with small-vessel coronary artery disease (CAD). We sought to evaluate the clinical efficacy of various PCI strategies for patients with small-vessel CAD through a network meta-analysis of randomized controlled trials (RCTs). We searched multiple databases for RCTs investigating the efficacy of the following PCI strategies for small-vessel CAD (<3mm in diameter): drug-coated balloons (DCB), early-generation paclitaxel-eluting stents and sirolimus-eluting stents (SES), newer-generation drug-eluting stents (DES), bare-metal stents (BMS), cutting balloon angioplasty, and balloon angioplasty (BA). The primary outcome was the trial-defined major adverse cardiovascular events (MACE), mostly defined as a composite of death, myocardial infarction, and revascularization. The secondary outcomes included each component of MACE and angiographic binary restenosis. We performed a sensitivity analysis for RCTs without BMS or first-generation DES. Our search identified 29 eligible RCTs, including 8,074 patients among the 8 PCI strategies. SES significantly reduced MACE compared with BA (hazard ratio 0.23, 95% confidence interval 0.10 to 0.54) with significant heterogeneity (I2=55.9%), and the rankogram analysis showed that SES was the best. There were no significant differences between DCB and newer-generation DES in any clinical outcomes, which was consistent in the sensitivity analysis. BMS and BA were ranked as the worst 2 for most clinical outcomes. In conclusion, SES was ranked as the best for reducing MACE. There were no significant differences in clinical outcomes between DCB and newer-generation DES. BMS and BA were regarded as the worst strategies for small-vessel CAD.

Mechanisms of very late stent thrombosis assessed by optical coherence tomographyin japanese patients

Abstract Background Although very late stent thrombosis (VLST) remains an important concern, the underlying etiology and clinical characteristics are not fully elucidated in Japanese patients who daily undergo intravascular imaging-guided percutaneous coronary intervention (PCI). Objectives The aim of this study was to explore the mechanisms of VLST in bare metal stents (BMSs) and drug eluting stents (DESs) in Japanese patients. Methods We identified 50 VLST lesions (BMS [n=16], 1ST generation DES [n=14], newer generation DES [n=20]) in patients managed in our institutes. The underlying mechanism of VLST was assessed by optical coherence tomography (OCT) and the major etiology of each lesion was determined. Results The median duration following stent implantation was 10 (range 1–20) years. The most frequent etiology of VLST was neoatherosclerotic rupture (44%) followed by neointimal erosion (24%). Edge disease (10%) and evagination (10%) were similarly observed. Malapposition (8%) was mostly acquired late by going back to the index procedure. Uncovered strut (2%) and in-stent calcified nodule (2%) were the least frequent etiologies. Regardless of etiology, signs of neoatherosclerosis were present in most (82%) lesions. Most patients received single (68%) or dual (8%) antiplatelet therapy or oral anticoagulation alone (4%), whereas considerable proportion of patients stopped any medication (20%). Regarding the treatment strategy, drug-coated balloon was the most frequent strategy (56%), followed by newer DES implantation (34%). Conclusion The mechanisms underlying VLST in Japanese patients were unique, with neoathersclerotic rupture and neointimal erosion accounting for two-thirds of cases of VLST. In these patients, biological responses seemed to be more relevant rather than index procedure-related factors.

Comparison of Endothelial Dysfunction in Coronary Arteries with Bare Metal and 2nd-Generation Drug-Eluting Stents.

Aims: Previous studies suggested that implantation with a 1st-generation DES was associated with coronary endothelial dysfunction, which was associated with Rho-kinase activation. Second-generation drug-eluting stents (DESs) may preserve coronary endothelial function in stented coronary arteries; however, because of methodological limitations, further study is needed to clarify the association between 2 nd -generation DESs and coronary endothelial dysfunction. Methods: We retrospectively analysed the CuVIC trial database, where we identified 112 patients who underwent coronary stenting in the left coronary arteries with either a bare metal stent (BMS, n =53) or 2 nd -generation DES ( n =59). We compared vasomotions of target vessels with stents and non-target vessels without stents. Furthermore, we measured the Rho-kinase activation detected in mononucleocytes from aortic and coronary sinus blood. Results: ACh-induced vasoconstrictive responses of target vessels were not enhanced with a 2 nd -generation DES (45±21% vs. 44±20%, P =0.56, paired t -test), but significantly enhanced in the coronary arteries with a BMS (50±18% vs. 42±20%, P =0.002). Rho-kinase activation did not differ between patients with a BMS and 2 nd -generation DES. In the target vessels with a BMS, large late lumen loss and acute coronary syndrome (ACS) at the index percutaneous coronary intervention (PCI) were associated with ACh-induced enhanced coronary vasoconstrictive responses. Conclusions: Evaluation of ACh-induced vasomotion of target vessels comparing with non-target vessels revealed that 2 nd -generation DESs were not associated with coronary endothelial dysfunction in target vessels, nor activation of Rho-kinase in the coronary sinus blood 6-8 months after stenting.

Clinical Implications of Bifurcation Angles in Left Main Bifurcation Intervention Using a Two-Stent Technique.

Objectives The aim of this study was to assess the clinical impact of 3 bifurcation angles in left main (LM) bifurcation treated with the 2-stent technique. Background Data are limited regarding the impact of bifurcation angles after LM percutaneous coronary intervention (PCI). Methods Using patient-level 4 multicenter registries in Korea, 462 patients undergoing LM bifurcation PCI with the 2-stent technique were identified (181 crush, 167 T-stenting; 63% 1st generation drug-eluting stent (DES), 37% 2nd generation DES). Three bifurcation angles, between the LM and left anterior descending (LAD), the LM and left circumflex (LCX), and the LAD and LCX, were measured. The primary outcome was target lesion failure (TLF), a composite of cardiac death, myocardial infarction, and target lesion revascularization (TLR). Results In patients treated with the crush technique, the best cutoff value (BCV) to predict TLF was 152° of the LM-LAD angle. In the crush group, a significantly higher TLF rate, mostly driven by TLR, was observed in the LM-LAD angle ≥152° group compared with the <152° group (35.7% vs. 14.6%; adjusted hazard ratio 3.476; 95% confidence interval 1.612–7.492). An LM-LAD angle ≥152° was an independent predictor of TLF. In the T-stenting, no bifurcation angle affected the clinical outcomes. Conclusions In LM bifurcation PCI using the 2-stent technique, wide LM-LAD angle (≥152°) was associated with a greater risk of TLF in the crush, whereas none of the bifurcation angles affected T-stenting outcomes.

P2696Clinical characteristics of late catch-up phenomenon after implantation of 2nd generation drug eluting stent

Abstract Introduction Late catch-up phenomenon (LCU) of 1st generation drug eluting stent (DES) has been increasing yearly despite the rate of restenosis in 1 year has reduced compared with bare metal stent (BMS). 2nd generation DES was more improved than 1st generation DES and suggested more benefits about clinical outcome. Purpose To investigate the incidence and predictor of LCU after implantation of 2nd generation DES and to evaluate the association between LCU phenomenon and adverse events. Methods Between August 2012 and July 2013, a total of 1665 consecutive patients (1956 lesions with elective/urgent PCI) were enrolled in SHINANO 5 years Registry (a prospective observational multicenter cohort study) from 13 institutions in Nagano, Japan. 711 patients that were treated with 2nd generation DES and 576 patients with BMS were selected. Exclusion criterias were cases of 1st DES, only POBA, only aspiration and chronic total occulusion. Results There were significant difference about patients background between BMS and 2nd generation DES groups. Those groups were matched with propensity score. After matching, 822 patients (BMS group 411 patients, 2nd generation group 411 patients) were analyzed. The rates of 2nd DES and BMS restenosis 5 years after initial PCI were 9.2% and 8.5% (p=0.572), those of LCU were 2.6% and 5.6% (p=0.043) by 1 year landmark analysis. Cox proportional hazards analysis revealed that the DES in-stent restenosis (ISR) lesion and higher HbA1c were independent predictors for LCU from 1year to 5year (HR 5.304, p=0.009, HR 1.254, p=0.015), but 2nd generation DES was not. Kaplan Meier curve showed no association between LCU phenomenon and all cause death (p=0.446). Cox regression analysis showed LCU was not independent predictor for all cause death (p=0.414). Conclusions Implantation to DES-ISR lesion with 2nd generation DES was associated with higher LCU. Despite of more complex lesions with 2nd generation DES, there were no differences of LCU incidence between 2nd generation DES and BMS. Acknowledgement/Funding None

The Development of Magnesium-Based Resorbable and Iron-Based Biocorrodible Metal Scaffold Technology and Biomedical Applications in Coronary Artery Disease Patients

In the treatment of atherosclerotic disease patients, the adoption of second-generation drug-eluting stents (DES) in percutaneous coronary intervention reduced the occurrence of in-stent restenosis (ISR) and acute stent thrombosis (ST) when compared to bare metal stents and 1st generation DES. However, the permanent encaging of the vessel wall by any of the metallic stents perpetuates the inflammation process and prevents vasomotion in the treated segment. Aiming to overcome this issue, the bioresorbable scaffold (BRS) concept was developed by providing transient vascular radial support to the target segment during the necessary time to heal and disappearing after a period of time. Close to 20 years since BRS technology was first reported, the interventional cardiology field saw the rise and fall of several BRS devices. Although iron-based BRS is an emerging technology, currently, magnesium-alloy resorbable scaffolds devices are supported with the most robust data. This manuscript aims to review the concept of magnesium-based BRS devices, as well as their bioresorption mechanisms and the status of this technology, and the clinical outcomes of patients treated with magnesium BRS and to review the available evidence on iron-based BRS technology.

Different Neoatherosclerosis Patterns in Drug-Eluting- and Bare-Metal Stent Restenosis - Optical Coherence Tomography Study.

There are few reports about the differences between drug-eluting stents (DES) and bare metal stents (BMS) in neoatherosclerosis associated with in-stent restenosis (ISR), so we compared the frequency and characteristics of neoatherosclerosis with ISR evaluated by optical coherence tomography (OCT) in the present study. Methods and Results: Between March 2009 and November 2016, 98 consecutive patients with ISR who underwent diagnostic OCT were enrolled: 34 patients had a BMS, 34 had a 1st-generation DES, and 30 had a 2nd-generation DES. Neoatherosclerosis was defined as a lipid neointima (including a thin-cap fibroatheroma [TCFA] neointima, defined as a fibroatheroma with a fibrous cap <65 µm) or calcified neointima. As a result, lipid neointima, TCFA neointima and calcified neointima were detected in 39.8%, 14.3%, and 5.1%, respectively, of all patients. The frequency of neoatherosclerosis was significantly greater with DES than BMS (48.4% vs. 23.5%, P=0.018). The minimum fibrous cap thickness was significantly thicker with DES than BMS (110.3±41.1 µm vs. 62.5±17.1 µm, P<0.001). In addition, longitudinal extension of neoatherosclerosis in the stented segment was less with DES than BMS (20.2±15.1% vs. 71.8±27.1%, respectively, P=0.001). OCT imaging demonstrated that neoatherosclerosis with ISR was more frequent with DES than BMS and its pattern exhibited a more focal and thick fibrous cap as compared with BMS.

Association of Subclinical Intrastent Thrombus Detected 9 Months After Implantation of 2nd-Generation Drug-Eluting Stent With Future Major Adverse Cardiac Events ― A Coronary Angioscopic Study ―

Detection of yellow plaques (YP) by coronary angioscopy (CAS) 1 year after 1st-generation drug-eluting stent (DES) implantation has been related to future coronary events. However, the association between CAS findings and clinical outcomes following 2nd-generation DES implantation has not been investigated. Methods and Results: This study included a total of 248 2nd-generation DES in 179 patients, who were examined by CAS 9±2 months after implantation. Angioscopic evaluation included dominant neointimal coverage (NIC) grade, heterogeneity of NIC, presences of YP and intrastent thrombus. The outcome measure was major adverse cardiac events (MACE) defined as a composite of cardiac death, acute myocardial infarction and any coronary revascularization. The association between the CAS findings and MACE was evaluated using the Kaplan-Meier method. A Cox proportional hazards model was used to assess the predictors of MACE. The mean follow-up duration was 1,367±843 days. Dominant NIC grade (P=0.98), heterogeneity of NIC (P=0.20) and YP (P=0.53) were not associated with the incidence of MACE. However, intrastent thrombus was significantly associated with MACE (P=0.033). Intrastent thrombus (adjusted hazard ratio: 2.22; 95% confidence interval [CI]: 1.12-4.39), acute coronary syndrome (2.83; 95% CI: 1.42-5.67) and B2/C lesion (2.13; CI: 1.12-4.05) were independent predictors of MACE. Subclinical intrastent thrombus observed by CAS at 9 months after 2nd-generation DES implantation was independently associated with poor clinical outcome.

Everolimus eluting stent vs first generation drug-eluting stent in primary angioplasty: A pooled patient-level meta-analysis of randomized trials

BackgroundSeveral concerns have emerged about the higher risk of very late stent thrombosis (ST) with first generation drug-eluting stent (DES) especially among STEMI patients. Newer generation DES has demonstrated to reduce ST at mid-term follow-up.Therefore, the aim of the present study is to perform an individual patient's data meta-analysis of trials comparing 1st generation DES vs. 2nd generation DES (everolimus-eluting stent, EES) in patients undergoing primary percutaneous coronary intervention (PCI) for STEMI. MethodsWe performed a formal search of electronic databases (MEDLINE and CENTRAL) and scientific session presentations from January 2010 to June 2016. We included all completed randomized trials comparing 1st vs. EES for patient presenting with STEMI. ResultsIndividual patients data were obtained from 3 trials, including a total of 1581 patients (686 or 43.4% randomized to 1st generation DES and 895 or 56.4% randomized to EES). At long-term follow-up (1584±588days), EES did not significantly reduce mortality (7.8.% vs 11.7%, HR [95%CI]=0.77 [0.52, 1.13], p=0.18, pheterogeneity=0.93), cardiac mortality (6.2% vs 7.6%, HR [95%CI]=0.90 [0.56, 1.44], p=0.65, pheterogeneity=0.85), and reinfarction (8.1% versus 11.2%, respectively; HR [95%CI]=0.74 [0.51, 1.07], p=0.11, pheterogeneity=0.52). However, EES significantly reduced the occurrence of ST (3.4% versus 6.1% respectively, HR [95%CI]=0.56 [0.32, 0.97], p=0.04, pheterogeneity=0.42) and target vessel revascularization (TVR) (14.2% versus 20.1%; HR [95%CI]=0.63 [0.42, 0.96], p=0.03, pheterogeneity=0.55). Landmark analysis showed more consistent benefits in ST with EES within 1year, whereas benefits in TVR were mostly observed later than 1year. ConclusionsThe present pooled patient-level meta-analysis demonstrates that among STEMI patients undergoing primary PCI, EES as compared to 1st generation DES is associated with a significant reduction in ST and TVR at long-term follow-up.

Mechanical abnormalities associated with first- and second-generation drug-eluting stent thrombosis analyzed by optical coherence tomography in the national PESTO French registry

Background and objectivesDES thrombosis may be triggered by different mechanisms that are difficult to identify by angiography alone. This work aimed to investigate and compare the characteristics of stent thrombosis (ST) between 1st- and 2nd-generation drug-eluting stents (DES) among a large cohort of patients explored by optical coherence tomography (OCT). Methods and resultsThe PESTO study was a prospective national registry involving 29 French catheterization facilities. Patients with acute coronary syndromes were prospectively screened for presence of definite ST and analyzed by OCT after culprit lesion deocclusion.The analysis involved 71 subjects including 34 patients with 1st-generation DES (DES1G) and 35 patients with 2nd-generation DES (DES2G). Most patients (80%) presented with very late stent thrombosis. The median time between initial PCI and ST was longer in DES1G than DES2G patients (3.8 [2.6–6.5] years vs. 1.1 [0.04–2.3] years, p<0.0001). OCT identified an underlying morphological abnormality in 96% of the cases. Significant malapposition was the main abnormality observed either in DES1G (26%) or DES2G patients (35%). Ruptured neoatherosclerotic lesions were more frequently observed with DES1G than with DES2G (26% vs. 3%, p=0.008). There was no significant difference in percentage of malapposed struts and uncovered struts between groups. ConclusionsIn this registry, DES thrombosis mainly occurred ≥1year after initial PCI. OCT identified a mechanical abnormality in the vast majority of the cases. Similar causes were observed between DES1G and DES2G, but neoatherosclerotic lesions were more common in DES1G.

COMPARISON OF CHRONIC ANGIOSCOPIC FINDINGS OF BMS, 1ST-GENERATION DES AND 2ND-GENERATION DES: A REPORT FROM JAPANESE MULTICENTER REGISTRY (MICASA)

This study was undertaken to assess neointimal coverage, color and presence of thrombus after bare-metal stents (BMS), 1st-generation drug-eluting stents (1st-DES), and 2nd-generation DES (2nd-DES) implantation, by using coronary angioscopy. MICASA is a multicenter registry of coronary angioscopy

Very very late stent thrombosis: 9.5 years after DES implantation

Very late stent thrombosis (VLST) has been recognized as a class effect of 1st generation drug eluting stents (DES) implantation. Although rare, VLST has been reported between 1 and 4 years after DES implantation. Very very late stent thrombosis (VVLST) occurring more than 5 years after DES implantation is extremely rare. We report the first case of a VVLST from India occurring 3465 days (9.5 years) after DES implantation with a brief discussion on its pathogenesis and prevention.

Insulin Resistance as a Predictor of the Late Catch-up Phenomenon After Drug-Eluting Stent Implantation

Percutaneous coronary intervention (PCI) is an effective treatment for patients with ischemic heart disease. In particular, restenosis is suppressed after drug-eluting stent (DES) implantation. However, several problems remain. Previously, we reported neointimal proliferation after DES implantation, which was associated with insulin resistance (IR). The aim of the present study was to clarify whether IR is associated with mortality and major adverse cardiac and cerebrovascular events (MACCE) after 1st-generation DES implantation. We researched the clinical records of 109 patients who had undergone elective PCI and DES implantation between May 2007 and December 2010. We segregated these patients according to the value of the homeostasis model assessment of IR (HOMA-IR) into Group P (n=63; HOMA-IR ≥2.5, positive) and Group N (n=46; HOMA-IR <2.5, negative), and examined the relationship between HOMA-IR and MACCE. The observation period was 7.4±1.6 years. There were no differences between the 2 groups in the occurrence of all-cause death, cardiac death, restenosis, myocardial infarction, stroke, heart failure, or stent thrombosis. However, the late catch-up phenomenon was significantly more common in Group P than in Group N (12.7% vs. 2.2% P=0.048). IR is a useful predictor of the late catch-up phenomenon after DES implantation, and improvement of IR may help to prevent the phenomenon. (Circ J 2016; 80: 657-662).

Safety of an abbreviated duration of dual antiplatelet therapy (≤6 months) following second-generation drug-eluting stents for coronary artery disease: A systematic review and meta-analysis of randomized trials.

Dual antiplatelet therapy (DAPT) is recommended for ≥12 months following coronary drug-eluting stents (DES) to reduce risk of major adverse ischemic events. Randomized trials suggest an abbreviated DAPT duration (≤6 months) is adequately protective. However, these trials are individually underpowered to detect differences in rare but serious events such as stent thrombosis (ST). We performed a meta-analysis of published randomized trials to define the impact of abbreviated DAPT (≤6 months) on death, myocardial infarction (MI), stent thrombosis (ST), and bleeding complications compared to standard-duration DAPT (≥12 months). Seven randomized controlled trials comparing abbreviated vs. standard DAPT regimens following DES use were identified by two independent investigators. Study characteristics were reviewed and clinical endpoint data were abstracted and analyzed in aggregate using fixed and random-effects models. The seven trials included 15,874 randomized patients. Second-generation DES were used in most patients. Compared to standard-duration DAPT, abbreviated DAPT was not associated with an increase in mortality (OR 0.93; CI: 0.73 to 1.17; P = 0.52), MI (OR 1.14; CI: 0.89 to 1.45; P = 0.30) or ST (OR 1.25; CI: 0.81 to 1.93; P = 0.31). Abbreviated DAPT was associated with significantly fewer major bleeding complications (OR 0.52; CI: 0.34 to 0.82; P = 0.005). The results were consistent between fixed and random-effects models, with no heterogeneity. Sensitivity analyses adjusting for inclusion of bare metal stents, 1st generation DES and/or abbreviated DAPT regimens of 3 months resulted in similar conclusions. In a meta-analysis of >15,000 patients primarily treated with second-generation DES, abbreviated-duration DAPT (≤6 months) was associated with a significant reduction in major bleeding complications with no evidence of a significant increase in risk of death, MI or ST. Accordingly, abbreviated DAPT should be strongly considered for patients receiving second generation DES.

IMPACT OF CHRONIC KIDNEY DISEASE ON CLINICAL OUTCOMES IN PATIENTS WITH DIABETES MELLITUS UNDERWENT PERCUTANEOUS CORONARY INTERVENTION USING DRUG-ELUTING STENT

Although there have been few studies regarding the adverse effect of chronic kidney disease (CKD) on clinical outcomes in diabetic patients undergoing percutaneous coronary intervention (PCI), most studies were conducted in the era of bare metal stent or 1st generation drug-eluting stent (DES). It

Coronary artery bypass surgery or coronary stenting in diabetic patients: too soon to make a statement?

Diabetic patients have been associated with poor procedural and long term outcome if they were treated either with percutaneous coronary interventions or coronary artery bypass surgery. Recently several randomized clinical trials (RCT) in this subset of patients have been published showing a greater incidence of major adverse cardiovascular events, death/myocardial infarction/stroke, if they were treated with first generation drug eluting stents (DES) which was not observed previously in the bare metal stent era. However, almost simultaneously with this data, several RCT demonstrated better safety profile with new generation DES including biocompatible polymers, biodegradable polymers and lately complete absorbable DES, all of them showed reduction in adverse cardiac events compared to 1st generation DES in patients with diabetes. In this editorial we review the old and new randomized data in diabetic patients and conclude that there are many unresolved issues to make a definitive statement regarding which is the best revascularization preference in diabetic patients and the measured final efficacy of PCI and CABG will not be reached until the arrival of RCT using next generation DES, including complete absorbable scaffolds.

Post-operative simultaneous very late two-vessel drug eluting stent thrombosis with sparing of bare metal stent in a Jehovah's witness after clopidogrel withdrawal

Very late stent thrombosis is a feared complication after drug-eluting stent (DES) implantation. Several factors related to the patient, generation and type of the deployed stent, procedure, and premature antiplatelet withdrawal are known to contribute to this complication. Herein, we describe a case of a Jehovah's witness patient who developed simultaneous two-vessel 1st generation DES thrombosis 5.4 and 3.5 years after deployment [with sparing of the bare metal stent (BMS)] in the immediate post-operative period secondary to clopidogrel withdrawal. The case was complicated by ST-segment elevation myocardial infarction, cardiogenic shock, and a ventricular fibrillation cardiac arrest requiring urgent percutaneous coronary intervention. The acute thrombosis of DESs with sparing of the BMS exemplify how they are more prone to this complication due to delayed endothelialization of stent struts and neoinitimal coverage.<Learning objective: Extreme caution should be excercised when attempting to withdraw antiplatelets immediately before surgery in patients with drug eluting stents even if the recomended 12-month period of dual antiplatelet therapy has elapsed because of the risk of very late stent thrombosis.>

Real-world comparison of angiographic and 2-year clinical outcomes between first and second generation drug-eluting stents in patients received overlapping stents

Background: There are few data comparing the efficacy of 1st and 2nd generation drug-eluting stents (DESs) in patients (pts) with long lesions who underwent percutaneous coronary intervention (PCI) by overlapping stenting. Methods: We compared mid-term angiographic and 2-year clinical outcomes of pts successfully treated with overlapping implantation of 1st generation DESs (DES-1; Cypher, Taxus, and Endeavor, n=1402) with 2nd generation DESs (DES-2; Xience V, Promus, Promus Element, Endeavor Resolute and Resolute Integrity, n=588) from June 2005 to January 2011. The pts with prior PCI and cardiogenic shock were excluded. Results: There were no significant differences in baseline clinical and lesion characteristics between the two groups except the DES-2 group had higher incidence in diabetes, multivessel disease, small vessel disease (>2.75mm in diameter), longer total lesion length, and higher stent numbers, whereas the DES-1 group had higher incidence of prior PCI, dyslipidemia, and cilostazol use. In multivariate logistic regression analysis, the incidence of binary restenosis, cardiac death, Q-wave myocardial infarction (MI), target lesion revascularization (TLR), target vessel revascularization (TVR), TLR- major cardiovascular event (MACE), and TVR-MACE were higher in the DES-1 group as compared with the DES-2 group (Table). ![Figure][1] Conclusions: In our study, the 2nd generations DESs were associated with superior efficacy and safety than 1st generation DESs in pts with diffuse long lesion undergoing overlapping stenting up to 2 years. [1]: pending:yes

Comparison of long term clinical outcomes between bare metal stent versus different types of drug eluting stents for treatment of acute myocardial infarction

Purpose: To overcome the intrastent restenosis (ISR) and stent thrombosis (ST), people have tried to make a perfect stent. Accordingly, now we come to have a lot of developed type of coronary stents. However, there is paucity of data to exclusively evaluate the safety and efficacy of bare metal stent (BMS) and different types of drug-eluting stents (DES) in the setting of AMI. The purpose of this study was to compare the clinical outcome of four different types of coronary stent including BMS, 1st generation DES, 2nd generation plus new generation DES, and most recently biodegradable polymer-coated stent in treatment of acute myocardial infarction. Methods: From Korean Acute Myocardial Infarction Registry (KAMIR) database, a total of 9,919 patients with acute myocardial infarction (MI) who underwent primary percutaneous coronary intervention (PCI) with BMS or DES were enrolled in this study. The patients were divided into four groups; BMS group (n=821), 1st generation DES group (n=2,751), 2nd generation plus new generation DES group (n=5,324), and biodegradable polymer coating stent group (n=303). The primary endpoints included major adverse cardiovascular events (MACE), such as death, MI, or revascularization including re-PCI and coronary artery bypass graft surgery (CABG), and stent thrombosis at one year follow up. Results: Baseline characteristics were similar between four groups. At one year follow up, MACE rate in the BMS, 1st generation DES, 2nd generation plus new generation DES, and biodegradable DES groups were 12.3%, 8.1%, 5.3% and 3.9%, respectively (p<0.0001). There were 104 cases of stent thrombosis of all cohorts, and the incidence of stent thrombosis was the lowest in the biodegradable DES group among the 4 groups (2.5%, 2.0%, 1.4%, 0.7%, p=0.007). After the adjustment of age, male gender, ST-segment elevation myocardial infarction (SETMI), left ventricular ejection fraction, stent number and length, stent type was significant predictor for one year MACE (Odds ratio of 1st, 2nd+new generation, biodegradable polymer coated stent group compared to BMS group: 0.62, 0.37, 0.27, respectively, p<0.05 for all). Conclusion: From our result, biodegradable polymer coated stent was the most efficacious and safest stent in acute MI at one year follow up.